The Eyexam Group, P.A.
125 Route 46 West
Totowa, NJ 07512
340 Route 17 North
Paramus, NJ 07652
THIS DOCUMENT DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
In the course of your care as a patient at The Eyexam Group, we may use or disclose personal and health related information about you in the following ways:
Your protected health information, including your clinical records, may be disclosed to another health care provider if it is necessary to refer you for further diagnosis, assessment or treatment.
Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are or may be responsible for the payment of services provided to you.
Your name, address, phone number, email address and/or your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, specialty offers, facility events and/or other health related information that may be of interest to you.
Examples of how we use or disclose information for treatment purposes are: testing or examining your eyes, prescribing glasses or contact lenses or medications and faxing or phoning them in to be filled.
You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the agreement of this office.
If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household. You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations. Alternate means of contact must be requested in writing.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
If we provide health care services to you in an emergency.
If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so.
If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
If we are ordered by the courts or another appropriate agency.
You have a right to receive an accounting of any such disclosures made by this office.
Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date.
Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.
We normally provide information about your health to you in person at the time you receive optometric care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or, if you would like the information in a specific form please advise us in writing as to your preferences.
You have the right to inspect and/ or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information. Requests to inspect, copy or amend your health related information should be provided to us in writing.
We are required by State and Federal law to maintain the privacy of your patient file and the protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect.
If you have any questions or concerns regarding our privacy notice, our privacy practices or any aspect of our privacy activities, please contact:
Dr. Loretta Clifford, The Eyexam Group Privacy Officer – Totowa Office
Dr. Minas J. Nicholas, The Eyexam Group Privacy Officer – Paramus Offices
If you have any further questions or concerns, you have the right to contact the Secretary of the Department of Health and Human Services. Please be assured that your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.
This notice is effective as of the date of execution listed below. This notice, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.
My signature acknowledges that I have read through this document and that upon my request I have received a copy of this notice for my personal records.
_____________________________ _____________________________ _____________
Patient Please Print Name Signature Date
If you are a minor, your parent or guardian must sign or in the event of other representation issues, please have the following executed by the appropriate representing party:
____________________________ _________________________ ______________
Guardian/ Representative Signature Date
Please Print Name
REFUSAL OF ACKNOWLEDGMENT
For office use only
For Location Use Only: This section is to be completed by the location only if unable to obtain the patient or patient’s legal representative’s written acknowledgment of receipt of the Notice of Privacy Practices for the following reasons:
_______ (Please initial here) Patient or Patient’s legal representative refused to sign.
_______ (Please initial here) Other: (Please specify, e.g.: emergency care)
Provider/Associate Signature Date